04 December 2008

No conversation in the ER that begins with "Hey, remember that guy from the other night?" is going to turn out well. It's an absolute law.

The case that the charge nurse was reminding me of was a young man whom I had admitted with a head injury. It was typical high-schooler foolishness: he was screwing around with his friends and managed to fall out of a moving car. The car was going pretty slowly when he exited the vehicle, maybe ten miles per hour, but he managed to hit hit head on the pavement on his way out. Concrete and asphalt are very unforgiving surfaces when they come into contact with a skull, and this case was no exception. He had a nondisplaced occipital skull fracture, and a tiny subdural hematoma.

Those injuries looked nonsurgical, but the bigger problem initially seemed to be the frontal lobe contrecoup contusion -- literally a bruise in the tissue of the brain. The frontal lobe of the brain is responsible for many of the higher functions, and the injury to this area causes a lot of functional impairment. In this case, the patient was showing signs of frontal release. He was agitated, confused, rambling incoherently, and (most disturbingly to his family) inappropriately hypersexual. He was, they reported, exceedingly well-mannered, ordinarily, and never even swore. But he was quite disinhibited by his injury.

His family was one of the nicest I have encountered in a long time. They really struck me by how great they were, even under substantial stress. They were warm and kind people, even taking time to thank all the nurses who cared for their son. I reassured them that his injuries, while serious, did not appear to be life-threatening. We had a long conversation about traumatic brain injuries and the potential complications and rehabilitation, and I felt that it really helped them get their heads around what had happened. They went up to the ICU, under the care of our neurosurgeon.

So it was with utter shock, five days later, that I heard the charge nurse finish her sentence: "You remember that guy the other night with the head injury? He just died upstairs!"

Apparently, his brain had swelled, and young people have tight heads -- not a lot of room in there for swelling. When the brain grows bigger, it displaces the cerebrospinal fluid from the skull, then can even cut off the blood flow as the pressures increase. A nuclear medicine scan had confirmed brain death.

It was terrible, but to me it was also incomprehensible. He had had a GCS of 14 when I took care of him, and just didn't have the hallmarks of someone at high risk for mortality. Should I have sent him to the regional trauma center? There was nothing really on initial presentation that implied he needed it. Other than getting a bolt -- an intracranial pressure monitor -- he never had developed lesion that could be addressed with surgery. Neurosurgery can be frustratingly futile, sometimes.

And I felt (and feel) terrible for his poor family. I bonded with them more than usual, and their suffering must be terrible. I went upstairs to the ICU after my shift, but they weren't around, and the transplant team was getting ready for harvest. The ICU nurses had a very grim satisfaction that it would be a "full harvest" -- all the organs were in great shape.

I don't really have a take-home point for this post. If I did, it might be: shitty things happen to nice people who don't deserve it. Or perhaps: this job will surprise you again and again, and you need to dispel that false sense of certitude when prognosticating. But whatever. Mostly, this was just a crappy case and I wanted to vent. Thanks for reading.

I think it needs to be said that few people could do what you do. Sure, there are highly intelligent people, and there are highly trained, highly organized and wickedly talented people, but being able to handle a tragic case like that and not turn on your heels and just pack it all in...well, I could never be that strong and compassionate at the same time, even if I had the brains to make it through med school (which I don't).

I guess what I'm trying to say is, while the brains requirement in your profession is a given, having a heart like yours will always be both curse and blessing, pain and jubilation--each a part of the other.

I had my heartbreak today over something kind of similar. I am do my social work (MSW) internship in acute rehab of the regional trauma center. We get all of the TBIs and Spinal cord patients from everywhere. Anyways, we have this little pumpkin.... We don't do kids in our hospital, but there was a tiny 10-12 year old transfered from the children's hospital for a TBI rehab.

He is trached (put plugged) and can only communicate by shaking his head (from the injury). But he makes eye contact all the time. Today he was having a bad day, you can just tell.

I got down to his level and we "talked."

Even now I am kind of teary eyed. He is just so young...I cannot imagine working in PICU.

I wonder why they didn't take out bone to give the brain some room? They often do w/young guys for the very reasons you mention. Caminos are, in my limited experience, not very accurate w/ICPs; they often get shoved up against something and don't read right.

The full harvest comment got me. I chose not to be an organ donor after seeing the state of a body (and the operating room) after a number of organs were harvested. Cripes. There was blood on the ceiling and flesh on the walls. Talk about disrespect for the dead.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

All Content is Copyright of the author, and reproduction is prohibited without permission.